DSRIP Difference logoEditor’s note: The DSRIP Difference is a new regular feature in Scoop, highlighting the progress being made through the UTHealth DSRIP (Delivery System Reform Incentive Payment) Projects, which are part of the Texas Healthcare Transformation and Quality Improvement Program Medicaid 1115 Waiver.

Recently, the coordinated care efforts between Dixie Blackstock, clinical case manager with DSRIP, and Dr. Julia Nassif, UT Physicians endocrinologist, likely saved a patient’s life.

Blackstock had been working from the disease registry and calling patients with diabetes who had not been seen by the clinic in several months to have their disease monitored. She spoke with one patient who had lost her insurance, been denied Medicaid, and most alarmingly, had not been taking insulin. Because of Blackstock’s vast knowledge and experience with disease management, specifically with diabetes, she was able to recognize subtle signs with the patient’s condition that warranted an immediate visit to the clinic. She contacted Nassif about seeing the patient the same day and was able to convince the patient to come to the clinic.

When the patient arrived, her blood sugar levels were off the charts. They were so high that Nassif could not get a reading. The patient was having some serious symptoms, and acute care was delivered to the patient on site. After fluids and insulin, the patient’s blood sugar finally lowered enough to be read. However, it was still dangerously high. The patient was transported to the emergency room and admitted.

Although we were not able to avoid a trip to the emergency room, because this patient was in the disease registry and contacted by Blackstock, she received the acute care she needed. Otherwise, she may not have made it through the weekend. She was admitted to the ICU and treated for diabetic ketoacidosis, a life-threatening condition.  The patient was discharged.

Social worker Christine Bakos-Block helped get her Medicaid application reopened and is helping the patient file for SSDI due to the disability caused by her diabetes. Nassif, Blackstock, and Bakos-Block worked in a coordinated manner to deliver patient-centered care which kept a patient from slipping through the gaps.

This success story is about how coordinated care within the medical homes model works to improve patient care and outcomes.  Nurse case managers, who manage a panel of patients with chronic diseases; social workers, who address related psycho-social issues; and community health workers (CHWs), who fill out the cultural competency needs, work with physicians in a team-based model of care that turns the traditional reactive model of care into a pro-active model of care.  This is the type of care that every clinician wants to give every patient, but is especially important for our most vulnerable and at-risk patients. The DSRIP projects being implemented at UT Physicians made it possible for Nassif to have the support of a nurse case manager, social worker, and CHWs that could reach out pro-actively to patients we haven’t seen in a while and work to ensure that they receive the care they need.  This is The DSRIP Difference.

-Dr. Sandra Tyson, executive director of UT Physicians Healthcare Transformation Initiatives